ELKHART COOPERATIVE EQUITY EXCHANGE CREDIT APPLICATION Personal Information Individual or Company Name Date of Birth Social Security Number or Fed Tax ID # Street Address City State Zip Home Phone Number ( ) Cell Pone ( ) Email Spouse or Partner Name Date of Birth Social Security Number or Fed Tax ID # Mailing Address City State Zip Home Phone Number ( ) Employment Current Employer Address of Current Employer Length of Employment Work Phone Number ( ) ************ Previous Employer Address of Previous Employer Length of Employment Phone Number ( ) Spouse or Partner s Place of Employment Spouse or Partner s Address of Employment
Length of Employment Work Phone Number ( ) Financial Information Name of Bank Where You Do Business Address of Bank Where You Do Business _ Phone Number ( ) Checking Account Number Single or Joint Savings Account Number Single or Joint Credit References Name Mailing Address City State Zip Account # Phone Number ( ) ************ Name Mailing Address City State Zip Account # Phone Number ( ) Credit Requested Purpose of Requested Credit Anticipated Max Charges/Month $ Credit Limit Desired $ The undersigned Applicant(s) hereby submit(s) the above information as being true and correct. Applicant(s) authorize(s) the above named creditor to make inquiries necessary to verify the accuracy of the statements contained herein and consent(s) and direct(s) that the person(s) name above are authorized to report such creditor, which is similarly authorized to report to other agencies or businesses regarding applicant(s) credit experience. Signature of Applicant Signature of Applicant s Spouse/Partner Date Date
820 Border Avenue * P.O. Box 210 * Elkhart, KS 67950 Phone (620) 697.2135 Fax (620)697.2910 DATE : AUTHORIZATION TO RELEASE CREDIT INFORMATION TO: Please be advised I have a credit account with your firm and hereby request that a report of my credit history with you be forwarded to the below listed company. You may consider this letter as my authorization to release this information. Thank you for you cooperation, Signature of Applicant Address Address Signature of Joint Applicant (if any) Company Requesting Report: Elkhart Cooperative Equity Exchange Attn: Credit Manager P.O. Box 210 Elkhart, KS 67950 620.697.2135 PHONE 620.697.2910 FAX
820 Border Avenue * P.O. Box 210 * Elkhart, Kansas 67950 Phone (620) 697-2135 Fax (620) 697-2910 CHARGE ACCOUNT AGREEMENT Acct Name: Date: Acct No.: The Elkhart Cooperative Equity Exchange agrees, if this agreement is approved by the association, that it shall allow the credit patron to purchase goods and services on credit and the credit patron agrees to pay for any goods and services in accordance with this agreement. DUE DATE: All purchases made on credit during the month that are reflected on the periodic billing statement for such month are due and payable upon receipt of the billing statement. Purchases are due by the 15 th of month. CONVENIENCE CREDIT: If the purchases are paid in full before the 15 th day of the month following the month of purchase, the account shall not be subject to any FINANCE CHARGE. FINANCE CHARGE: Any balance not paid before the 15 th day of the month following the month of purchase shall be subject to a FINANCE CHARGE of 2.0% per month or 24% per year. Said FINANCE CHARGE to apply to the unpaid balance on the account on the last day of the billing cycle carried over from the prior month, and the minimum amount of such charge shall be $1.00 per month. TERMINATION OF CREDIT: Elkhart Coop Equity Exchange reserves the right to terminate credit sales to the patron at any time without prior notification and in addition thereto, no additional credit purchases will be allowed to any account that is over 30 days past due. If an account is delinquent for six consecutive months, a new credit application must be provided; confirmation of satisfactory credit obtained and the Board of Directors must give approval in order to have credit restored to the account. CHANGE IN TERMS: This agreement may be changed by Elkhart Cooperative Equity Exchange to increase the FINANCE CHARGE, change the due date, change the billing cycle, change the method of calculating the FINANCE CHARGE or change the matters of similar nature within the limitation of the applicable law. Notice of any such change
shall be given to the patron thirty (30) days before the effective date of the change in accordance with KSA 16a-3-204 or as hereafter amended. SECURITY FOR ACCOUNT: Any purchase(s) made pursuant to this agreement shall be secured by a security interest and lien in any investment the patron may have in Elkhart Cooperative Equity Exchange. Investment means any stock, stock or membership credit or revolving fund or patronage ledger credit. The credit patron does not have the right to demand offset of such investment on his account. Such an offset may be made only at the discretion of Elkhart Cooperative Equity Exchange Board of Directors. COLLECTION/ATTORNEY FEES: Credit patron agrees to pay the reasonable costs of collection, including, but not limited to, attorney and collection agency fees (but not both), and court costs, but such fees may not exceed 15% of the unpaid debt after default, in accordance with KSA 16a-2-50-7, or hereafter amended. AGENCY: Until notified in writing to the contrary by the credit patron, Elkhart Cooperative Equity Exchange may assume that the credit patron(s) = spouse, children over the age of sixteen years, and employees, if any, are authorized to purchase goods or services and charge them to the credit patron account. Customer/Patron Signature Joint Signature (if any) Note: The Federal Equal Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sec, marital status, age (provided that the applicant has the capacity to enter into a binding contract); because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with the law concerning this creditor is the Federal Trade Commission, Equal Credit Opportunity, Washington DC 20580. Please advise the Elkhart Cooperative Equity Exchange if you wish any credit information regarding this account to be reported in the names of both spouses.
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